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Privacy Breach Nugget: When Patient “Success Stories” Become a Privacy Breach

Privacy Breach Nugget: When Patient “Success Stories” Become a Privacy Breach

​When Patient “Success Stories” Become a Privacy Breach

Privacy Breach Nugget

Ever wonder how privacy breaches happen—and what you can do to stop them? Privacy Breach Nuggets takes real cases and turns them into practical lessons for privacy officers, clinics, and healthcare practices. Let’s unpack today’s case and explore what went wrong, what worked, and how you can apply these insights to protect patient information.

What Happened

Cadia Healthcare Facilities, which is a rehabilitation, skilled nursing, and long-term care services provider with 5 locations located in Delaware, US.

Cadia posted patient names, photographs, and detailed health information on its public-facing website as part of a marketing campaign featuring patient “success stories.” These disclosures were made without obtaining valid written authorization from the patients whose information appeared on the website.

4 Step Privacy Breach Response

Cadia’s management of the privacy breach can be examined using the 4 Step Response Plan framework.

Step 1 – Spot and Stop

Cadia had procedures that required employees to obtain a written consent from patients before sharing their testimonials. Despite this, the Office of Civil Rights (OCR) received a complaint in September 2021 alleging that patient information had been disclosed without authorization.

OCR’s investigation ultimately confirmed that the protected health information (PHI) of 150 patients had been disclosed without proper authorization. Cadia was formally notified of these findings in February 2022.

Step 2 – Investigate

Cadia conducted an internal investigation and on March 2022 removed all the success stories from their social media and website and ended the marketing campaign.

However, during this process, the organization deleted the content before confirming which patients had valid written consent on file, making it more difficult to accurately determine the full scope of unauthorized disclosures.

Step 3 – Notify

Cadia initially failed to notify affected patients of the privacy breach, as required. Notification obligations were later addressed as part of the enforcement process. A public notice regarding the breach can now be found on the Cadia website.

Step 4 – Prevent the Breach from Happening Again

According to the OCR settlement details:

  • Cadia agreed to pay a $182,000 USD penalty
  • A Corrective Action Plan (CAP) was imposed, including two years of OCR monitoring and reporting
  • Cadia failed to properly implement its existing administrative privacy policies
  • Cadia is required to:
    • Revise its privacy policies and procedures
    • Provide privacy training to all staff, including marketing personnel
    • Implement stronger authorization processes before using patient information for marketing
  • Cadia must now notify all affected individuals whose PHI was disclosed without authorization

 

Website and Social Media Tips

Custodians are responsible for ensuring that patients’ health information is collected, used, and disclosed in compliance with health privacy legislation, such as Alberta’s Health Information Act (HIA) and Ontario’s Personal Health Information Protection Act (PHIPA).

It’s also important to ensure your practices align with professional college standards related to advertising, professionalism, and confidentiality.

Here are key questions to include in your website and social media compliance checklist before collecting or using patient testimonials:

  • What is your clinic’s approval process before content is posted online?
  • Has the patient provided written consent for their information to be used?
    • If a photograph is included, does the consent explicitly authorize the use of images?
  • Who authorizes the content before it is published?
    • For example: the healthcare provider, lead custodian, social media lead, or privacy officer?
  • Before posting, has the content been reviewed for compliance with:
    • Health privacy legislation?
    • Professional college standards?
  • Does your marketing vendor understand your privacy obligations?
    • Do you have a written agreement in place requiring the vendor to protect the confidentiality of personal health information?

Also See

Is your website secure? Take the Website Self-Assessment from Elevated Business Solutions.

Do you have a website for your healthcare practice in Ontario? PHIPA Website Guide from Elevated Business Solutions will help you.

Take-Aways

The Cadia case is a reminder that policies alone are not enough. Clinics must ensure that privacy requirements are understood, followed in practice, and applied consistently across all teams, including marketing and external vendors. Taking the time to review your website and social media practices now can help prevent a costly and public privacy breach later.

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Medical Secretary Fined for Unauthorized Access And Disclosure to Health Information

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References

Cadia Healthcare Facilities. Notice of Success Story Incident. https://cadiahealthcare.com/wp-content/uploads/2025/06/Cadia_Notice-1.pdf

Health and Human Services. HHS’ Office for Civil Rights Settles HIPAA Investigation of Cadia Healthcare Facilities for Disclosure of Patients’ Protected Health Information. 2025Sept30. https://www.hhs.gov/press-room/ocr-settles-hipaa-with-cadia-healthcare-facilities.html

Help Me With HIPAA. Did Anyone Even Ask If It Was OK? – Ep 531 podcast. 2025Oct17 https://helpmewithhipaa.com/did-anyone-even-ask-if-it-was-ok-ep-531

Privacy Breach Nugget: Why Documentation Matters in Privacy Breach Investigations

Privacy Breach Nugget: Why Documentation Matters in Privacy Breach Investigations

Investigation Tips Following the NWT Health Authority Incident

When employees make mistakes that result in a privacy breach, the custodian is held responsible to ensure that appropriate investigations are performed. This includes appropriate documentation of the privacy breach incident and sanctions when indicated.

The NWT Information and Privacy Commissioner (IPC) opened an investigation into the Northwest Territories Health and Social Services Authority (NTHSSA) after a reported privacy breach in 2024. This review aimed to assess whether the health authority had adequate safeguards in place to investigate and prevent similar future incidents.

Privacy Breach Nuggets takes real cases and turns them into practical lessons for privacy officers, clinics, and healthcare practices. Let’s dive into what went wrong, what worked, and how you can apply these insights to strengthen your privacy program.

What Happened

In April 2024, a patient filed a complaint with the nurse-in-charge at a health centre in the Northwest Territories. The complaint alleged that a clerk had inappropriately shared the patient’s personal health information with a family member during a casual conversation.

The nurse-in-charge apologized to the patient and escalated the issue to the regional manager. The clerk denied disclosing the health information, but the health authority concluded the incident had indeed occurred.

The Commissioner emphasized that there was no ill intent, stating:

“The interaction between the clerk and the sister was spontaneous and indicates a simple lapse in judgment.”

Managing the Breach

The NTHSSA’s management of the privacy breach can be examined using the 4 Step Response Plan.

Step 1 – Spot and Stop

The privacy breach was identified by the patient and reported to the nurse in charge and escalated to the regional manager.

Step 2 – Investigate

An investigation was initiated. While the clerk denied the allegation, the health authority determined a breach had occurred.

However, the Commissioner noted a serious concern: the investigation was poorly documented. If notes were taken, they could not be located or produced during the review.

Step 3 – Notify

The patient and NTHSSA (the custodian) was aware of the breach. No further notification was required.

Step 4 – Prevent the Breach from Happening Again

The health authority directed the clerk to:

  • Complete updated privacy training
  • Review the oath of office
  • Review patient confidentiality policies

No further disciplinary action was taken.

Commissioner’s Investigation

The IPC made several key recommendations:

  • Equip investigators: Ensure staff who investigate privacy breaches are properly trained and supported to conduct effective, timely, and well-documented investigations.
  • Enforce sanctions: Ensure managers understand the range of disciplinary options available and are aware of their obligation to apply reasonable disciplinary measures when warranted.
  • Annual privacy training: Reinforce the Mandatory Training Policy by ensuring all employees complete refresher privacy training every year.
  • Use real examples: Incorporate this privacy breach as a case study in future privacy training to help employees understand their obligations—at work and outside of work.

Take-Aways

Annual privacy training is not enough.

Training must include real-world, job-relevant examples and emphasize how privacy rules apply in everyday situations.

When employees make mistakes, it’s the custodian’s responsibility to lead an appropriate and well-documented investigation—not just revisit outdated training.

A strong privacy culture includes tools, training, and clarity. Equip your investigators, privacy officers, and managers with the skills they need to respond appropriately.

For more on how to manage privacy-related employee errors, listen to the podcast:

Managing Employees When They Make Mistakes – Episode #105

Need Help Training Your Privacy Team?

Ask me about Practical Privacy Officer Strategies training to strengthen your internal investigation process and build a more resilient workplace.

Reference

NWT IPC File Number: 24-950-6 on April 4, 2025Northwest Territories Health and Social Services Authority (Re), 2025 NTIPC 97 (CanLII), <https://canlii.ca/t/kc0s6>, retrieved on 2025-06-09

You May Also Be Interested In

Medical Secretary Fined for Unauthorized Access And Disclosure to Health Information

3rd Largest Fine Ever Under the HIA

Why You Need Policies and Procedures

Why You Need Policies and Procedures

 

Why You Need Health Information Policies and Procedures

Maybe you’ve heard you need written policies and procedures for your health information, but you’re left asking yourself why it’s so important?

The truth is, without written policies and procedures, you open a healthcare practice up to a whole host of problems, including major legal issues.

In fact, every business needs good practices that apply to your:

  • Information that you collect from patients/clients
  • Website
  • Email
  • Business practices including electronic (or paper) patient records, and computer network
  • Financial information
  • Billing, collection, and payment processing

Within the healthcare industry, there are additional legislation requirements that require specific written health information policies and procedures.

The Health Information Act (HIA) and the Personal Information Privacy Act (PIPA)

As we mentioned, when a custodian collects health information, you must follow the Health Information Act (HIA) in Alberta.

Like most other private businesses in Alberta, private healthcare practices must also comply with the Personal Information Privacy Act (PIPA).

The colleges of regulated health professionals (like the Alberta Dental Association and College (ADAC) and the College of Physicians and Surgeons of Alberta (CPSA), require dentists and physicians to meet the standards of practice which includes compliance to HIA and PIPA legislation.

In addition, the college has other standards of practice that you must meet, including policies and procedures for the collection, use, disclosure, and access of health information.

So, let’s explore further why written policies and procedures are so essential, as well as what can happen without them, and why healthcare practices may not think they need them in the first place.

Benefits of Policies and Procedures

One of the most critical benefits of having policies and procedures in place is that they’re good for business.

Here’s how:

  • They contribute to consistent, efficient workflow.
  • You can figure it out once, write the procedure, tweak it to make it better, and then repeat the same procedure again and again.
  • They help you make better business decisions, like buying supplies, choosing services, and selecting vendors.
  • They help support your accreditation efforts.
  • On-boarding employees the right way with no missed steps is much easier with policies and procedures in place.

If you’re looking for even more proof of the benefits of having written procedures, it can also help you avoid:

  • Internal disputes within your team and external disputes with your patients and clients
  • Re-work and re-training employees
  • Poor customer service
  • Poor reputation
  • Fines and penalties

Fines And Penalties For Not Having Written Policies And Procedures

You might be wondering why you would face fines and penalties for not having written policies and procedures in the first place.

The HIA requires the custodian – which includes the physician, pharmacist, dentist or dental hygienist – to take reasonable safeguards to protect the privacy and confidentiality of patients’ health information.

Having written policies and procedures is a common, expected, and reasonable safeguard.

Let’s say you have a privacy breach in your practice or an error (like sending a fax to the wrong number or you are a victim of a phishing or ransomware attack).

You can learn more about what makes a privacy breach a privacy breach here.

If you can’t demonstrate that you had the appropriate reasonable safeguards, like written policies and procedures in place, you are guilty of an offence under the law.

It’s illegal not to have policies and procedures when you collect health information.

If you are guilty of this offence, you are liable for a fine of a minimum of $2,000 and not more than $500,000. (HIA section 107(7)).

3 Policies and Procedures Myths

One reason some healthcare practices fail to have written policies and procedures is because they believe they don’t need them.

Often, this is because they’ve fallen prey to the common myths about policies and procedures.

There are 3 of the common myths that stop healthcare providers and their clinic managers from creating written policies and procedures:

  1. It’s Too Hard

While it does take some skill to write clear, easy to read, and easy to understand policies and procedures, it doesn’t have to be heard. In fact, you can even purchase templates to make this easier.

  1. It Takes Too Much Time

Writing policies and procedures does take some time.

But investing the time to create policies and procedures pays off by preventing suffering from inconsistent or broken procedures, using or disclosing health information in error, and having to pay fines, penalties, public relations nightmares, or spending the time required to run a privacy or security investigation.

  1. It’s A Waste Of Time

Here are a few good reasons that prove writing policies and procedures is not a waste of time:

  • Practical privacy policies and procedures will create a more efficient practice and help you make better business decisions.
  • The policies and procedures become the foundation of your privacy impact assessment.
  • Policies and procedures are pre-requisites for other initiatives, like access to Netcare or other community integration initiatives, and privacy impact assessment (PIA). Click here to learn more about PIAs.
  • You must have them as part of your legislative compliance.
  • It’s the law. Not having policies and procedures regarding the collection, use, disclosure, and access of health information is illegal.

As you can see, written policies and procedures help ensure consistent office procedures and good communication between team members in your healthcare practice.

In addition to those good reasons, you must have good written policies and procedures about how you collect, use, disclose, and provide access to health information to avoid legal problems, fees, penalties, and other problems.

 

Not Sure Which Policies and Procedures That You Need?

Show Me Policy And Procedure Checklist
 

Did you enjoy this article? If you’d like to look at similar posts, visit these links:

Do You Know Where Your Policies and Procedures Are? 

Privacy Impact Assessments (PIA)

Policy and Procedure Checklist book image
Privacy Principles Applies After Death

Privacy Principles Applies After Death

 

Privacy Principles Applies After Death

Are your staff looking at medical records when they shouldn’t be?

Many people have the mistaken impression they can look at a patient’s medical records as long as they don’t tell anyone else.

It’s not okay.

We continue to see examples of snooping where both seasoned and new healthcare providers and support staff don’t realize that looking at patient’s health information—even with good intentions—is a serious privacy violation.

As privacy lawyer Kate Dewhirst puts it

  • Privacy = Don’t look
  • Confidentiality = Don’t tell

Despite years of experience, many healthcare professionals still need a refresher on the basics. Privacy awareness training remains essential.

In this article, I am sharing an example of the Ontario’s Information Privacy Commissioner (IPC). This case involves a privacy complaint submitted by the family of a deceased individual. It’s a good reminder that whether you’re running a brand-new clinic or managing an established practice, it’s critical to understand your legal responsibilities and have systems in place to protect patient information.

What Happened

In 2014, a physician accessed a deceased patient’s health records while acting in his role as a coroner. The patient was also a family member. Soon after, the family alleged that the physician continued to access the individual’s personal health information (PHI) contrary to Ontario’s Personal Health Information Protection Act (PHIPA).

The family submitted a complaint to the hospital. Initially, the hospital’s response did not satisfy the family. The family filed a complaint to the Information and Privacy Commissioner (IPC) of Ontario.

The IPC started a complaint investigation.

privacy principles after death privacy breach incident scenario diagram

Privacy Complaint Investigation

Under PHIPA, the hospital is a health information custodian and the physician is an agent of the hospital.

During the IPC investigation, the physician admitted he “accessed the health information in response to his concern about the individual’s well-being.”

“I know now that proceeding in this way was misguided and wrong.” He would never disclose the information to anyone; that would be a violation of patient privacy and a breach of doctor – patient confidentiality.

He acknowledged he misunderstood the difference between:

• Privacy: The general right of every individual (living or deceased) to limit access to their health information.
• Confidentiality: The duty to not share that information once accessed.
• Circle of care / Need to know: You must only access information required to provide care at that moment.

4 Step Response Plan

When you have a privacy breach, follow these four steps to manage the privacy breach incident.

Step 1 – Spot and Stop the Breach

The family’s complaint prompted the hospital to begin the first step to spot and stop the breach.

Step 2 – Evaluate the Risks

An initial risk assessment was conducted, and after the IPC got involved, the hospital re-opened the investigation. They completed a comprehensive review and used audit log reporting tools to trace access.

Step 3 – Notify

The hospital eventually informed the family of the privacy breach—but the notification wasn’t timely. A more thorough and timely response could have helped address the family’s concerns more effectively.

Step 4 – Prevent the Breach From Happening Again

Following the breach, the hospital implemented several improvements:

  • Introduced a new auditing program that enhances its ability to detect unauthorized access.
  • Updated its Privacy and Confidentiality Policy, which applies to all agents of the hospital.
  • Launched mandatory annual electronic privacy training program for all staff, volunteers and learners. Physicians must complete this training as part of the annual reappointment process.
  • Strengthened the privacy warning on its electronic system, which warns users that unauthorized use of personal health information may result in disciplinary action.

privacy principles after death sanctions

The hospital’s Medical Advisory Committee also recommended disciplinary actions:

  • A three-month suspension of the physician’s hospital privileges
  • Three years of enhanced monitoring of his access to patient records
  • A requirement to present at Grand Rounds on privacy topics upon his return

The IPC concluded that the disciplinary consequences for the physician were sufficient in the circumstances.

Privacy Breach Nuggets You Need to Know

Privacy breaches are in the news every day. Here’s how you can be proactive to prevent privacy breach pain.

  • Go beyond policies—model good practices
  • Use real-life examples in staff meetings
  • Incorporate gamification and ongoing discussions to engage your team

Privacy awareness is everyone’s responsibility. Make sure your staff know what’s expected, what’s at risk, and what to do if something goes wrong.

If you need to start or update your privacy awareness training program, check out the on-line education Privacy Awareness in Healthcare: Essentials.

When we know better, we can do better…

I’ve helped hundreds of healthcare practices prevent privacy breach pain like this. If you would like to discuss how I can help your practice, just send me an email. I am here to help you protect your practice.

PRIVACY BREACH NUGGETS are provided to help you add a ‘nugget’ to your privacy education program. Share these with your staff and patients as a newsletter, poster, or staff meeting.

Jean L. Eaton, Your Practical Privacy Coach

References and Resources

Dewhirst, Kate. After Death: Who Can Access The Records Of A Patient After Death? May 7, 2019. https://katedewhirst.com/blog/2019/05/07/after-death-who-can-access-the-records-of-a-patient-after-death/

Ontario Information and Privacy Commissioner IPC Investigation Report PHIPA DECISION 74 HC15-4 Sault Area Hospital August 10, 2018.

3 Parts to Every Privacy Awareness Training Plan

3 Parts to Every Privacy Awareness Training Plan

Reasonable Safeguards – the Myth

You may have heard the myth that the Health Information Act (HIA) is a big scary thing that will interrupt your routine, rob you of countless billable hours, impact all of your staff, turn your office inside out, and change the way that you run your entire business!

Myth Buster

The HIA provides structure and framework for reasonable safeguards that apply to any healthcare business.

One of the requirements of reasonable safeguards includes having a privacy awareness training plan.

Click the >> arrow to play the video

Privacy Awareness Training

Your Privacy Awareness Training Plan should include learning objectives throughout the year, including

  • Orientation – Standardized training curriculum provided to everyone in you healthcare practice at the time of employment. This is often included during a new employee’s orientation period.
  • Specific – Privacy training that is more detailed and specific to the roles and responsibilities of that individual’s job in your healthcare practice. There may also be specific training when new software, technology, or procedures are introduced anytime throughout the employment.
  • Reward – Keep privacy awareness top of mind all year long. Recognize and reward when individuals follow privacy principles that also add value to your client satisfaction or business efficiency.

It is reasonable to expect regular privacy awareness training, especially at orientation, and a formal review annually.

What a Privacy Awareness Training Plan Can Do For You

When you implement regular privacy awareness training, you will see:

  • Privacy and security expectations clearly communicated among your team.
  • Team members demonstrate their commitment to privacy, confidentiality, security of personal health information.
  • Efficient practices that protect the privacy and save you time and money
  • Team members confidently and correctly handle personal health information using reasonable safeguards

Are You a Myth-Buster?

You can be a myth-buster, too, and implement privacy awareness training in your healthcare practice.

You can easily implement reasonable safeguards and meet HIA requirements to ensure privacy, confidentiality, and security of health information that saves you time, frustration and money.

If you need a little help, I have written a practical privacy awareness training course designed for the community health care practice. This is ideal for orientation of new employees and a refresher for the rest of us.

Privacy Awareness in Healthcare: Essentials

Understand basic health care privacy principles and how to handle personal information, use safeguards, and recognize and report a privacy breach.

Ideal for community-based health care professionals and staff, direct care providers, or anyone working with a health care, dental, or social services organization.

An effective privacy compliance program promotes organizational adherence to the Health Information Act (HIA), Personal Information Protection Act (PIPA) Alberta, Personal Health Information Protection Act (PHIPA) Ontario and the Personal Information Protection of Electronic Documents Act (PIPEDA) requirements. A compliance program is your first line of defense to promote the prevention of criminal conduct, and enforce government rules and regulations, while providing quality care to patients. All three training products help protect practices against privacy and security breaches, improper payments, fraud and abuse, and other potential liability areas through education.

Canadian Health Care Privacy Training Solutions

Corridor’s online training makes it easy for health care organizations to comply with provincial and federal legislation that mandates regular privacy training for all health care providers, staff, and vendors.

Select the training that best fits your needs:

NEW! Privacy Awareness in Healthcare Training: Dental Practices – Alberta

Dentists and dental practices in Alberta are required to have an ongoing privacy program to ensure the protection of private records and patient information. The appropriate collection, use, and disclosure of personal information is critical to maintaining privacy for patients that choose to trust in your practice. Accomplishing this important goal demands an up-to-date training strategy.

Privacy Awareness in Health Care Training – Canada

Includes detailed resources for each province and territory with key terminology and links to applicable privacy legislation. Resources are provided for our ten provinces: Alberta, British Columbia, Manitoba, New Brunswick, Newfoundland & Labrador, Nova Scotia, Ontario, Prince Edward Island, Quebec, Saskatchewan, and three territories: Northwest Territories, Nunavut and Yukon. This new product is ideal for both organizations and vendors who provide health care services or have health care clients in more than one province.

Privacy Awareness in Health Care Training – Alberta 

Includes the mandatory privacy breach notification amendments to the Health Information Act (HIA).

Privacy Awareness in Health Care Training – Ontario

Specifically covers all legislation and rules specific to the province of Ontario including the Personal Health Information Protection Act (PHIPA).

Refresher: Privacy Awareness in Health Care – Alberta

A quiz-based review of Corridor’s full Privacy Awareness course. The Refresher starts with an initial quiz to assess knowledge on the topics and information covered in the full course. Based on the quiz results, one or more of eight Refresher topic quizzes must be completed, each focusing on a specific subject area. The Refresher also includes access to the original course content.

 

Privacy Awareness in Healthcare: Essentials

Grab your on-line course from Information Managers and Corridor Interactive

for just $30 per individual 3 month subscription now!

Click Here to Grab Your On-Line Privacy Awareness Course Now!